What Causes Reflux and Silent Reflux in Babies?
Isn't reflux just something that some babies have and they will grow out if it?
No. It isn't.
Have you been told that "reflux is normal"?
Well, reflux isn't normal, it's common. That's not the same as it being normal.
I'm here to tell you something different. Very different. The complete opposite in fact.
Reflux is not a disease (despite it's name).
Reflux is not normal, it is common. These are not the same thing.
Reflux can be resolved (I prefer to use this term than "cure" because it isn't actually a disease so does not need a cure)...
And you don't have to put your life on hold waiting for your baby to grow out of it.
Let me take you on a journey of explanation...
What is Gastro Oesophageal Reflux?
Let’s break it down into its simplest components -
- Gastro means stomach,
- Oesphageal is into the oesophagus
- And reflux is involuntary regurgitation
It is simple - when something moves from the stomach into the oesophagus, a "reflux" event has occurred.
This process is completely normal, our bodies are designed to be able to do this for various reasons, for example getting rid of excess air from the stomach - or burping, and unwanted food or bacteria - vomiting.
And as adults our bodies retain this capability as a means of supporting our digestive system and preventing attack from anything the body deems harmful such as viruses, bacteria and poisons.
So, yes, Gastro Oesophageal Reflux events are normal.
What is not normal is when this happens all the time, and causes pain and distress. Yes the ability to expel air from the stomach is normal, and yes the ability to vomit a perceived "poison" or pathogen from the body is normal.
- It is not normal for this to happen all the time,
- it is not normal for stomach acid to be present in the oesophagus all the time and
- it is not normal to assume that this is normal.
This, however, does not offer any solace to parents of babies who continue to suffer.
Our medics describe GOR Disease (GORD / GERD) as GOR that causes "marked distress".
For some clarity, let’s look at the definition from the Cambridge English Dictionary for disease.
"(an) illness of people, animals, plants, etc., caused by infection or a failure of health rather than by an accident".
I believe the formal definition of GORD/GERD is wrong because it is not a disease. It is a dis-ease, a discomfort: it has no underlying pathology and therefore is not an illness.
Sure, vomiting can be caused by an ingested virus, but this isn’t reflux disease, this is a stomach bug.
I also disagree with medical literature when it says that GORD is "normal". The ability to burp is normal, the ability to vomit is normal. When it happens on a continual and regular basis, with or without distress, it is not normal.
For example, some babies vomit, a lot, and yet because they are not upset by it, and as a result they don’t gain as much weight as they should, or it causes distress to parents who often implement bigger feeding regime, yet the doctors will say that the vomiting is normal, and baby is gaining weight therefore it is not reflux disease. And without this label, both baby and parents are pushed away without answer and without support.
Yet even this constant vomiting worries parents, and I believe that this is not ”normal”.
There is a reason for the frequent or constant vomiting and once we understand the reason we can resolve it.
What does not cause Gastro Oesophageal Reflux?
In infants, the causes of reflux are not a "weak lower oesophageal valve", nor an over production of acid in the stomach. Here's why...
Why Reflux is not cause by a "weak lower oesophageal valve"
All babies are born with underdeveloped muscles. We witness this every moment with our babies - they cannot control their own limbs as movement is governed by muscle control and they simply do not have muscle control or strength in the early days and months. In my opinion, every baby is born with a "weak lower oesophageal valve". And it doesn't cause every baby an issue.
Yes, of course there are exceptions to the rule, and there are some rare cases where baby's have low muscle tone (Ehlers Danlos Syndrome) or hypotonia. However, this should not prevent us from understanding everything that is going on for these babies because then we can take more specific action to minimise the impact to them.
Reflux is not cause by an overproduction of stomach acid
Our stomachs are precise and complex systems. They produce stomach acid in response to the presence of food in the stomach. This is not a cause of reflux. This is completely normal. And the production of stomach acid does not force stomach acid into the oesophagus. If it did, there wouldn't be room for food in the stomach, ever, and we would literally "overfill" ourselves...
In fact, there are only two occasions when the stomach truly does over produce stomach acid and this is when babies are starting on gastric acid suppression medications (like ranitidine, a Histamine Receptor Antagonist, H2RA; and drugs that end in "-prazole", the Proton Pump Inhibitors, PPI), and when they are weaning off them.
This is when the "acid battle" happens, and I do not believe in battling with a baby's body to get it to succumb to the medications.
There are a few cases where medications are the right answer, but these are about 15-20% of cases in my opinion.
Why does Reflux happen?
There are a lot of underlying causes of reflux, outlined in this short video, below this, I’ll explain the two greatest direct causes in more detail.
Reason 1: Air
Grey’s Anatomy explains that reflux happens when the pressure in the stomach is greater than the pressure in the oesophagus.
We all know, that things tend to move from areas of high pressure to area of low pressure, they will naturally try to even things out. We see this every day in the changes in our weather. And we all know the sort of explosive force a build up of pressure in a small stretchy container can have... Have you ever witnessed the bursting of a balloon? This is exactly the same mechanism at work in baby’s stomach.
When the pressure inside baby’s tummy is greater than the pressure in the oesophagus, and depending on how big that pressure difference is, that will determine the nature of the vomit that comes with it. Higher pressure results in projectile vomit and lower pressure presenting as silent reflux.
Now when these explosive events happen, what comes back into the oesophagus can be just milk, or milk mixed with stomach acid. The longer the milk has been in babies tummy, the more acidic the reflux will be.
What we need to understand, is what is causing the pressure in the stomach to be greater than the pressure in the oesophagus?
It happens is because there is too much air in baby’s tummy.
And air gets into baby's tummy when they drink, cry, laugh, in their milk and when they swallow saliva.
Reason 2: Stomach Perception
Our stomach plays a vital role in immunity. Gastric acid is known to destroy many bacteria to prevent them reaching the small intestine and causing infection (1).
Our baby's stomach's perceptive ability is immature, and in some cases it makes mistakes. For example, it can interpret, rightly or wrongly, that a protein in cow's milk or soy, is a virus (which have protein structures) and so it vomit's it out as a way to protect the body. In fact, this perceptive mistake can happen with any complex protein that does not get broken down sufficiently in infancy.
The stomach identifying the food as something it doesn’t think is safe and saying “I don’t want this in my body”, and then creating a reflux-like reaction (vomiting, regular vomiting, to expel the perceived "threat" from the stomach) event to protect itself.
In the case of food allergies, the reflux is a symptom of the allergy.
What do we do about it?
While some of the symptoms and presentation may be the same, however the underlying cause of reflux in one baby to another can be different.
There are multiple other reasons that reflux happens, including pyloric stenosis, galactosaemia, intestinal blockages, etc so it is really important that we fully assess each case on an individual level.
When we give each child this 1-2-1 focus on their symptoms, this is when we get to help them quickly and effectively. In many cases completely resolving, or curing their reflux.
There is no reason that a baby who has a food allergy should be on reflux medications yet this seems to be the first place many medics go with babies presenting this way.
Your baby is telling you everything you need to know, through their symptoms and behaviours. And I have spent the last six years deciphering these into the various patterns that result in reflux.
So How Do Medications Address Reflux Causes?
Reflux medications do not address the cause of reflux.
Their function assumes that baby's stomach is producing too much stomach acid, which it isn't. What is happening is that the stomach acid is being regurgitated and this causes pain. The medications strive to prevent the regurgitation, or to change the acidity of what is regurgitated so that it doesn't cause damage to the oesophagus.
I've created a comprehensive Interactive Medications Guide - all contained within the Reflux 101 resource area. Find out more here.
If you liked this blog, you might also be interested in:
- How to Wean Your Baby Off Reflux Medications
- How Do I Know If My Baby Has Reflux? What are the symptoms?
How to Cure Baby Reflux
The starting point for ALL babies and toddlers, regardless of their age, is to understand what symtpoms they are expericing that are connected to their reflux (this includes colic, silent reflux, CMPA and other allergies and intolerances as they all have cross-over symptoms).
Download your free Baby Reflux Sypmtoms Tracker right now and get started by understanding which of your baby's symptoms are related to their reflux.
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